The Changing Face of the Social Determinants of Health: Implications for Hospitals

Rapidly shifting societal demographics impact SDoH.

2018 saw the Social Determinants of Health (SDoH) rise to be among the most popular hot topics for the healthcare industry. In 2018 alone:

• $1.7 trillion in care was attributed to 5 percent of the population.
• ICD-10 coding reimbursement for the SDoH took place through:
  • Use of non-physician documentation by members of interprofessional care teams able to substantiate SDoH and assign the ICD-10 Z Codes (55-65) to recoup payment.
  • Implementation of human trafficking and “T” codes, with clinical and appropriate documentation, to substantiate (physician and non-physician).
• Close to 80 percent of payers evolving SDoH-related programming.
  • 42 percent integrated community programs and resources into their population health programs.
  • 34 percent combined census and socioeconomic data with clinical data.
• Vertical mergers to address housing, pharmacy, mental health, and fitness deserts.
  • The Blue Cross Institute studied the Zip code effect, expanding contracts with Lyft and Walgreens.
  • The Intermountain community partners collaboration
  • Kaiser Affordable Housing Program
  • Montefiore Hospital Housing Program

Among the most compelling examples of how this topic made headlines:

• More than half of hospital readmissions are related to the SDoH alone, including patients with:

• Higher “transportation access risk,” with an average of 41 percent more excess days in the hospital (than those with less risk). Note that transportation access risk is the risk of not having access to private or public transportation for basic health-related activities (e.g. to get to medical appointments or a pharmacy to fill a prescription). 
• Higher “home instability risk,” patients who are 32 percent more likely to exceed the average hospitalization length of stay (LOS); home stability risk is the risk of eviction or foreclosure of one’s residence, and risk of not being able to afford necessary home utilities.

With all that has been done to address the SDoH, what is on the horizon, and what is the ongoing impact for hospitals?

The Changing Face of Care

Rapidly shifting societal demographics have few persons excluded from the SDoH ranks. The focus on society’s most vulnerable and disenfranchised has been a constant theme of hospitals and healthcare organizations alike. For years, hospitals had deep pockets to support, often finance, and provide care for their populations. However, current socioeconomic issues faced by patients (e.g. food insecurity, unemployment, lack of or limited insurance and financial resources, housing insufficiency, and access to care challenges) call into question what can realistically be provided. These needs have prompted a ripple effect on clinical treatment outcomes. Even those organizations with the largest budgets and most resources are scaling back by shifting their program acceptance criteria (e.g. limiting the maximum fiscal amount to be provided, plus adding state or other types of residency requirements). The ethical dilemma of who receives what benefits has become a challenge of grand proportions for most healthcare organizations and their employees.

Along with traditional populations dealing with the SDoH, new attention has been focused on the following:

• Victims of natural and/or manmade disasters
• Residents of rural health regions
• Persons faced with a sudden change in financial status or loss of income due to business closures and government shutdowns, plus older adults who lose pensions
• Victims of social isolation and loneliness
• Members of the LGBTQ community faced with societal stigma or family abandonment
• Homeless veterans
• Adults living with disabilities (e.g. physical and intellectual)

The three “R’s” for providers and hospitals have been reimbursement, resources, and readmissions.

Regarding reimbursement, emerging federal and state rules have increased funding for non-clinical services that address health outcomes, such as food, education, employment, and healthcare access.

You might have suspected that in this article I’d also give a subtle reminder of the importance of the ICD-10 “Z” codes of 55-65. I continue to be amazed at the degree of disbelief I witness when I discuss these codes, and the ability to use non-documentation during presentations and trainings for healthcare organizations and other audiences. People start taking pictures of my slides depicting the codes, as though they were the answer to all their reimbursement prayers. Well, they just might be. With focus on persons with potential health hazards related to socioeconomic and psychosocial circumstances, ample reimbursement is possible. Click here to access the ICD University webcast.

Don’t forget to add those codes for human trafficking to your professional scope as well.

Medicaid Expansion

This expansion is now at 37 states and counting, as there have also been enhanced services for the following:

• Opioids and substance abuse:
  • A total of 38 states reported coverage of methadone in 2018
  • Expanded treatment options, including short-term residential options
  • New demonstration projects for programming geared to children and pregnant women
• Potential increases to funding in rural areas
• Increases to fund previously excluded programs for immigrants (e.g. Medicaid, the Supplemental Nutrition Assistance Program (SNAP), the Medicare Part D Low-Income Subsidy Program, and several housing assistance programs)
• Options and services to address long-term services and supports (LTSS) for persons in home and community-based settings
• Medicaid MCOs are to address SDoH as part of contractual agreements – for example, In New York, the Value-Based Payment Roadmap offers startup funds for MCO partners in value-based payment agreements conducting SDoH-related interventions.

Increased Resources

Proactive spending on enhanced resource management and service optimization, with greater ability to connect with needed resources, yields a reduction in costs, unnecessary emergency department visits, poor health outcomes, and especially readmissions. Evidence is mounting that countries that spend more on resource provision for non-clinical social services (e.g. disability, unemployment, housing, transportation, public health) have better population health outcomes. The Organization for Economic Co-Operation and Development (OECD) identified that increasing spending for social services contributes to:

• Higher life expectancy
• Lower infant mortality and all mortality rates
• Lower prevalence of chronic diseases

Education

General Education Development certificates (GEDs) are now covered by some Medicaid plans. AmeriHealth Caritas, a Philadelphia-based managed Medicaid plan in Pennsylvania and five other states, connects members with GED test preparation classes and telephone coaching to keep members on track. They also pay the associated testing fees. This program is consistent with recommendations seen earlier in the year related to Medicaid work requirements, discussed last July 10 on Monitor Mondays:

• Instead of putting work requirements in place, amp up covered health benefits and support services provided by the plans. Expansion of and increased linkage to address the SDoH factors has been demonstrated to make a difference for beneficiaries who live with the realities that most directly impact health outcomes.

WellCare, a Tampa-based health plan covering 2.2 million Medicaid recipients in Missouri, Nebraska, Georgia, Kentucky, Hawaii, and Illinois, found that close to 20 percent of recipients did not have a high school diploma or GED. They set up a similar program in 2012, and more than 225 members have sat for the exam. 

Rather than pay a set fee each month to cover members’ health costs, many states are implementing policies for health plans to share in any savings they can demonstrate. That provides motivation for insurers to address factors such as literacy and poor housing, which can drive up health costs. Attention to the SDoH can’t be paid by Managed Care Organizations (MCOs) alone, though ensuring the availability of dedicated benefits to compensate for them is an important first step!

A five-month program offering 10 home visits from healthcare professionals significantly decreased disability in low-income older adults with a self-reported disability. CAPABLE (Community Aging in Place-Advancing Better Living for Elders) costs $2,825 per participant and results in Medicare cost savings of $22,000 per participant. Healthcare organizations in 22 cities and rural areas in 11 states have implemented the CAPABLE program.

With Medicare not typically paying for nonmedical services, funding for programs like CAPABLE has traditionally been challenging to identify. However, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 offers opportunities to amend this fact. The law, which passed the Senate, provides flexibility to Medicare Advantage plans and Accountable Care Organizations (ACOs) for coverage of nonmedical services, such as bathroom grab bars and wheelchair ramps for patients identified as high-need and/or high-risk. The current status can be viewed on the URL provided above.

Readmissions

Addressing downstream issues prompting poor health outcomes will in turn address readmissions. The industry must get ahead of the factors that impact and interfere with health outcomes.

With $566 million in readmission penalties slated for the first quarter of 2019, the industry is on notice. Huge costs impact safety net hospitals. In October 2018, Medicare accounted for the longstanding complaint from safety net hospitals about the inequities of readmission penalties, equalizing the playing field. Their high percentage of low-income patients is more likely to suffer complications post-hospitalization, through no fault of the institutions, but due to lack of access to appropriate resources. Medicare sanctions will be halved for these institutions.

Penalty changes are also in store across the continuum. A 3 percent increase was slated for specialty hospitals, and nursing homes are receiving increased scrutiny. A total of 73 percent of Skilled Nursing Facilities (SNFs) received a penalty for readmissions in 2018, with data showing a dramatic decrease in the effectiveness of facilities to manage ongoing care of their residents. It has been suggested that the SNFs perform worse on readmissions due to increased pressures from providers to shorten lengths of stay. Many of the residents impacted live on fixed and limited incomes, face isolation and limited social support, and are beneficiaries of Medicare and Medicaid.

2020 will see the Patient-Driven Payment Model replace the resource utilization groups model currently in place. The new system will have five patient categories: nursing, non-therapy ancillary, physical therapy, occupational therapy, and speech training, as an attempt to add more precision to the payment system. The hope is that providers will receive more accurate reimbursement reflecting the costs for care of all SNF residents. Like most Centers for Medicare & Medicaid Services (CMS) funding initiatives, time will tell how this payment shift will play out.

What Else?

More is on the horizon to address the SDoH. The industry must ensure an appropriate response to the costliest factors that impact the health and wellness of populations and organizations. Stay tuned for further broadcasts and publications on this very evolving topic.

Program Note:

Listen to Ellen Fink-Samnick report on SDoH on Talk Ten Tuesday today at 10 a.m. Eastern.

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